Massachusetts Child Psychiatry Access Project Newsletter August 2012 Vol. 1 No. 8

In this issue Cannabis: A Danger to the Adolescent Brain – Cannibis; a Danger to the How Pediatricians Can Address Marijuana Use Adolescent Brain – How By Elaine Gottlieb Pediatricians Can Address Marijuana Use Experimenting with sex, alcohol, and drugs is common during adolescence. School Avoidance Among illicit drugs, marijuana is the most commonly used. The liberalization of High on Bath Salts: What marijuana laws and increasing availability of medical marijuana have led to to Know greater acceptance of the drug among adults and adolescents who view it as non- Behavioral Health Learning addictive and less harmful than other drugs. and Events A recent survey of Massachusetts students showed a decline in the perceived harmfulness of marijuana and a reversal of a decade-long decrease in marijuana use. According to the CDC national Youth Risk Behavior Survey (YRBS), 43 percent About Us of Massachusetts teens have used marijuana one or more times. “Teens think About MCPAP that if marijuana is used as a medicine, it must be safe,” says John Kulig, MD, MCPAP Data MPH, Director, Adolescent Medicine, Tufts Medical Center, and Professor of Frequently Asked Questions Pediatrics, Public Health and Community Medicine, Tufts University School of Contact Us Medicine. “Teens who say they would never smoke tobacco admit they do smoke marijuana.”

Services This is a dangerous trend, as new advances in developmental neuroscience show Services for Primary Care that adolescent brains are differentially vulnerable to the neurotoxic effects of Clinicians cannabis. As a result, an American Academy of Pediatrics AAP policy statement recommended against the legalization of marijuana because it might lead to Toolkits increased use among adolescents. “The earlier an adolescent starts smoking, the earlier the potential changes to brain structure and function,” says John Knight, Toolkits MD, Senior Associate in Medicine and Associate in Psychiatry, Children’s Hospital Boston and Associate Professor of Pediatrics, Harvard Medical School. Diagnoses ADHD Marijuana’s Effects on the Adolescent Brain Autism Neuroscience has shown that the human brain continues to develop into the mid to late twenties.¹ During the first decade of life, brain growth occurs mainly in the Bipolar gray matter (neurons and dendrites) and during the second and third decades, it Conduct Disorder occurs primarily in the white matter (connectivity). Exposure to neurotoxins Depression during the brain’s developmental period can permanently alter the brain’s Eating Disorders structure and function.² The main psychoactive substance in cannabis is delta-9-tetrahydrocannabinol Obsessive Compulsive Disorder (THC). When marijuana is smoked, THC moves quickly from the lungs to the Oppositional Defiance bloodstream and the brain, causing an immediate “high.” THC acts on the Disorder endocannabinoid system, which is present in the fetal brain and plays a critical Post-Traumatic Stress role in normal brain development and function; it affects the growth, Disorder differentiation and final positioning of neurons as well as connectivity among Postpartum Depression neurons.³ THC binds to two major cannabinoid receptors, CBR1 and CBR2. CB1 receptors are concentrated in the hippocampus (memory), amygdala (emotion Schizophrenia and anxiety), nucleus accumbens (reward and motivated behavior), Substance Abuse hypothalamus (appetite, stress), basal ganglia (movement), and cerebellum (muscle coordination).⁴ CB2 receptors are located mainly in the immune system.⁵ Team Bios Like other addictive substances, such as opioids, THC activates the reward system Tufts Medical Center by stimulating the release of dopamine.

Baystate Medical Center Exogenous cannabinoids such as THC can disrupt the development of neural UMass Medical Center pathways, especially in adolescents who are chronic marijuana users. “When you North Shore Medical Center interfere with connectivity, there are changes in higher order thinking and Massachusetts General memory,” says Dr. Knight. Hospital “While there is conflicting information related to cannabis’ long-term McLean-Brockton neurocognitive effects, there is no debate that adolescence is a very vulnerable time to put extraneous substances into the brain. While some adolescents report Website being able to use marijuana without a major negative impact, they are not always www.mcpap.com aware of the deficits in learning and memory related to their use,” says Mona Potter, MD, Child and Adolescent Psychiatrist at The Landing/Dual Diagnosis Adolescent Residential Treatment Unit at McLean Hospital.

Marijuana and Mental Health Disorders Early marijuana use is associated with the development later in life of serious mental health disorders: addiction, major depression, anxiety, and psychotic disorders such as schizophrenia. One systematic review estimated a 40 percent increase in the risk of psychosis among adolescents who had tried cannabis and a 50 to 200 percent increase among more frequent, heavy users.⁶ Daily use of cannabis in high school is associated with a six-fold increase in depression and anxiety later in life.

Taking high doses of marijuana can cause short-term acute psychosis with symptoms such as hallucinations, delusions, and loss of the sense of personal identity. “Cannabis is a very impairing drug; it’s just as dangerous as alcohol and stays in the system much longer,” says Dr. Knight.

Cannabis use can lead to amotivational syndrome which impedes learning and schoolwork. “These kids have muddled brains; they can’t participate in group or individual therapy, can’t think straight, or make life plans. Users think they are more creative when they smoke marijuana but they only feel more creative,” says Dr. Knight. Contrary to popular belief, marijuana is addictive: there are more youths in treatment for marijuana dependence than any other drug. Cannabis causes both the physiologic symptoms of drug withdrawal as well as psychological dependence. Some adolescents who are addicted to opiates “report finding it harder to quit marijuana than opiates. They are surprised that it isn’t as easy as they thought it would be,” says Dr. Kulig who treats opioid-dependent youth.

When adolescents use marijuana they are “learning a certain way to cope with life. Instead of, for example, learning how to handle anxiety, they use marijuana. It blunts personal and developmental growth,” says Dr. Potter.

Risk Factors Adolescents who smoke marijuana may have parents who are permissive or who are smokers (30 percent of suburban parents use marijuana), have friends who use the drug, have poor academic performance, or be involved in other negative behaviors, such as drinking alcohol and smoking cigarettes.

Habitual users may have a family history of drug or alcohol abuse or comorbidities such as depression and anxiety. “If you’re anxious and depressed, do you use marijuana to self-medicate or does the drug itself cause the symptoms?” says Dr. Kulig.

Discussing Marijuana Use with Adolescents Pediatricians can have a major influence on adolescent marijuana use. Dr. Knight recommends discussing drugs and alcohol with patients starting at age nine or ten to prepare them for middle school, where they will be exposed to older students who smoke, drink, and take drugs. Teens may not be aware that today’s marijuana is more potent than in the past and therefore has a more powerful effect.

The AAP-recommended CRAFFT screening tool (www.ceasar-boston.org/CRAFFT) includes six simple questions designed to assess whether a longer conversation about drugs and alcohol is warranted. “Teens are usually forthcoming and honest when you have a trusting relationship and they believe you are concerned about them,” says Dr. Kulig.

Explaining the science behind marijuana’s harmful effects to teens is very effective, reports Dr. Knight. “When I talk to students, I explain how marijuana affects the brain in an easy-to-understand way. Kids are fascinated with the science. They are confused about medical marijuana and have many questions about it,” he says.

Dr. Knight also tells students that marijuana “affects athletic performance and grades. Kids all want to be successful and win ‘American Idol.’ You’re not getting an edge when you’re screwing up your brain.”

Don’t use a confrontational approach, advises Dr. Potter, as it alienates teens. Instead, “discuss the pros and cons of using marijuana and have them argue for the cons to help reinforce them,” she says. If a teen uses marijuana to cope with difficulties, such as social anxiety, discuss other coping strategies.

Parents also need to be educated: “Kids who don’t use marijuana say ‘my parents would kill me.’ Parents have more influence than they think: they need to communicate repeatedly to their teens that they shouldn’t smoke marijuana. Some parents want to be ‘cool’ parents but adolescents don’t need cool parents; they need parents,” says Dr. Knight.

Signs of Possible Marijuana Abuse The signs of marijuana abuse are behavioral rather than physical. Teens exhibit a slow decline over time: they lose interest in school, work, and extracurricular activities and withdraw from family members. They are apathetic and are friends mostly with other drug users.

Pay particular attention to adolescents with comorbidities: nearly 60 percent of regular marijuana users have at least one co-occurring disorder, such as ADHD, a learning disability, depression, anxiety, or PTSD.

MCPAP has recently received several telephone calls regarding cannabis and cannabis-induced psychosis. These calls and a recent request from a pediatric practice in central Massachusetts prompted us to focus on this issue. MCPAP- enrolled practices that have a question regarding cannabis or possible co- occurring disorders should feel free to seek help by calling their MCPAP regional hubs.

Addressing Marijuana Abuse To address chronic marijuana use in adolescents, it’s important to involve parents. Adolescents who are daily users should see an addiction specialist or be referred to a local drug treatment program. “Every clinician needs to know about community substance abuse resources,” says Dr. Kulig.

If a teen is resistant to treatment, try to persuade him or her to have an assessment. When you make referrals, “stay involved with patients and monitor their progress. Pediatricians have known teens over time and can help support them during treatment,” says Dr. Potter.

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By discussing marijuana’s negative effects starting at a young age, keeping up communication during adolescence, and paying attention to signs of chronic marijuana use, pediatricians can help prevent marijuana’s damaging effects on neurological and psychological development.

References All references relate to: Jebaraj S, Knight J, Harris SK. Medical marijuana is bad for youth. The Forum. Massachusetts Chapter of the American Academy of Pediatrics. Fall 2011, Vol. 12, No. 4

School Avoidance: Why Does Johnny Refuse to Get on the Bus?

By Michele Casoli-Reardon, MD

School phobia is defined as a child’s refusal to attend part or all of a school day. From grade school to high school, avoidant and phobic children pose a problem for both school systems and physicians. Here in Massachusetts, truancy rates range from 2 percent in some school districts to as high as 12 percent in others. Truancy has a high cost on society, as children who drop out of school have higher rates of drug and alcohol use, delinquency, unemployment, poor health, and early pregnancy.

Identifying Children at Risk Identifying children at risk of school avoidance and truancy is important, as early and aggressive intervention can prevent children from becoming overwhelmed and experiencing school in a negative way. At well-child visits, asking how many days of school a child missed in the past year may identify these children early.

Often, the reasons why a child avoids school are not simple, and it is important to recognize, treat, and address all contributing factors in order to successfully treat the child. Too often, when a child presents with a set of behaviors, we focus on the behaviors instead of trying to understand what the child is trying to communicate through those behaviors. The “anxious” child may not always have an underlying anxiety disorder but may instead be struggling with issues around learning, organization, or mood.

Causes of School Avoidance Why then do kids struggle with going to school?

School avoidance can stem from social, familial or neuropsychiatric factors.

Social For children living in urban areas, gangs, guns, bullying, or poorly maintained facilities can make schools unsafe environments. Children who are recent immigrants with a language barrier can feel isolated and anxious as they try to keep pace with a curriculum that they are unable to understand. For even the most motivated students, school can become impossible in these conditions.

Social factors can play a particularly important role in school avoidance in middle and high school where interactions with peers often have profound effects on the child’s experience of school. Bullying, which can begin as early as the higher grades of elementary school, creates an environment that feels unsafe and isolating. Although many schools have implemented anti-bullying programs and professional training programs, bullying may be difficult to detect as children are often hesitant to seek help from adults and it goes unreported. Another issue is that the “bully often gets bullied,”: these children may have a history of being victimized by bullying as well as victimizing others. Working with children early on to teach them the necessary social skills and empathy that can prevent bullying is important not only at school but at home as well. A physician may want to have a discussion with a vulnerable child and family early on to try to prevent bullying.

Familial Family situations can also interfere with a child’s education. For some families, education is not valued or is less important than their personal and financial needs. Older children may be expected to watch younger siblings or work and be pressured to drop out of school. To avoid detection of abuse or neglect by schools and social service agencies, families may keep children at home.

These children may present with defiant, hyperactive, aggressive, or even inappropriate sexualized behaviors to schools or physicians.

It is important to remember that certain groups of children are at greater risk of harm and abuse, and there may be overlap with symptoms and disorders, including ADHD, autistic spectrum disorder, and mental retardation. It is important to screen for other disorders when seeing children with a history of abuse as they may also have underlying psychiatric issues.

Neuropsychiatric Many psychiatric factors can lead to school avoidance and phobia in children. If not addressed, these conditions lead to higher rates of school failure and drop outs. It is not uncommon for adult patients to report dropping out in mid-high school because of panic attacks in crowded hallways or feeling “paranoid” in classrooms. Frequently, these students are not diagnosed until they develop truancy problems and others begin to question why.

Anxiety disorders including social phobia, OCD, and panic disorder can all present at various points during the school years. The younger child with OCD may present with separation anxiety and avoidance related to fears of harm to family members. The young child with social phobia may also try to avoid school and be selectively mute within the classroom.

As children age, they may avoid school because of OCD fears of getting sick or dying and have frequent visits to school nurses or their primary care physician with multiple somatic complaints. The “perfectionist” OCD child may present as rigid and oppositional with school and routines but later fool teachers and physicians as they ritualistically overwork to attain high grades. This can become exhausting even for the brightest of students, and it may not become obvious how much distress these children are in until they begin to avoid school.

Panic attacks and agoraphobia (fear of open spaces) typically occur at school between classes when the child is walking in the halls. Lunchtime, assemblies and time between periods can be very stressful for these students and lead them to eventually avoid school. Making small accommodations for these children, such as allowing them to switch classes early, can often alleviate much of their anxiety.

ADHD and other learning disabilities, such as dyslexia and nonverbal learning disability, can cause a variety of academic and behavioral issues in class. This behavior may be the only indication of the child’s underlying academic struggle, as he or she may still make “effective progress” within the classroom. The complexity of the frontal lobe and its pathophysiology in ADHD often cause a myriad of behaviors and symptoms that extend beyond attention and impulsivity. Children may present with tantrums and meltdowns (precipitated by frustration), oppositionality, anxiety (secondary to disorganization), aggression, poor social skills with peer conflicts, rigidity and transition difficulties, “laziness” (from amotivation), and a tendency to disrespect teachers. Identifying these students early, before their experiences with school become negative and unhappy, is critical to preventing truancy. Pediatricians should also be aware that there is high overlap and co-morbidity between school avoidance and many childhood psychiatric disorders, so it is important to look for other disorders.

An increasing number of children are being diagnosed at the mild end of autistic spectrum disorders. For this group of children, the risk of peer conflict and bullying is high. There may also be co-morbid learning disabilities and peer issues, which, along with academic struggles, can lead to frustration and feelings of isolation. These issues and underlying anxiety disorders can put children at risk of avoidance and eventual truancy as they enter middle school and high school.

Mood disorders, whether primary or secondary to another disorder, can present in grade school but typically have onset during puberty. Social withdrawal, anger, irritability, drops in grades, and loss of interest in activities should alert parents and physicians to the possibility of a mood disorder. Truancy may become an issue both because of anhedonia (loss of interest) in relation to school as well as insomnia that may interfere with the child’s ability to get up in the morning.

Children may become defiant, irritable and hyperactive in the classroom, eliciting negative responses from teachers, which increases their sense of isolation and negative self-esteem. Drug and alcohol abuse may develop as a coping mechanism, and these children may spend more time away from school as they gravitate to children on the periphery who are also truants. In general, both substance abuse and oppositional behavior are not seen as separate issues but often as symptoms of the underlying problem and the child’s attempt to communicate what is going on.

Understanding that behavior is a symptom and correctly interpreting a child’s behavior allows for appropriate and successful treatment. Without understanding, we often intervene in a counterproductive manner.

Contacting MCPAP MCPAP-enrolled primary care clinicians who have questions related to school avoidance can contact their MCPAP regional hub.

High on Bath Salts: What to Know Not your typical “bath salts,” these products are intended to be snorted, smoked or injected. According to the American Association of Poison Control Centers, they have been sold on the Internet and gas stations under street names such as “Blizzard” “Cloud Nine” and Ocean Snow”.

They contain the psychoactive chemicals mephedrone and/or methylenedioxypyrovalerone (MDPV), which have properties similar to methamphetamine, coca leaves and ecstasy.

Side effects can include tachycardia, hypertension, psychosis and paranoid delusions. The psychosis can cause extreme violent, combative and self-injurious behavior; the most profound effects from overdose include seizure, rhabdomyolitis and renal failure.

The neurological effects last 3-4 hours and the physical effects, such as hypertension and tachycardia, as long as 6-8 hours. MDPV is undetectable in routine urine and blood tests; the special, costly tests that can detect MDPV have a window of 48-72 hours.

Treatment is symptomatic and supportive, involving fluid administration, benzodiazepines for chemical sedation, and physical restraints for severe combativeness. Psychiatric monitoring is recommended until psychotic ideations pass.

Reports to poison control centers have increased from 303 in 2010 to 4,720 by August, 2011.

This article was originally published in a July issue of the SmartCare2 E-News. San Diego-based SmartCare2 is a member of the National Network of Child Psychiatry Access Programs. We thank our sister program for allowing us to publish this information.

Behavioral Health Learning and Events The American Academy of Pediatrics is presenting a series of webinars on providing services at the medical home for children and adolescents exposed to violence. To find out more about this series and to listen to archived webinars please visit the following link: http://www2.aap.org/sections/childabuseneglect/MedHomeCEV.cfm#Educat ion

©MBHP August 2012